Diploma Unit IA - Element IA2 - Loss causation and incident investigation
NEBOSH International Diploma in Occupational Health and Safety
July 2014
Element IA2
Loss causation and incident investigation
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Learning outcomes
Licence details
ACT Associates Limited
Victoria House, Lower High Street, Stourbridge DY8 1TA
IA2.1 Explain the theories of loss causation
IA2.2 Explain the quantitative analysis of accident/incident ill‐health data, limitations of their application, and their presentation in numerical and graphical form
IA2.3 Explain the external and the internal reporting and recording systems for loss events (injuries, ill‐health, dangerous occurrences) and near‐misses
IA2.4 Explain loss and near‐miss investigations; the requirements, benefits, the procedures, the documentation, and the involvement of and communication with relevant staff and representatives
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Third Edition December 2013
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Issued to:
Single Licence
Licence No:
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Contents
IA2.1
IA2.2 Unit IA
International Management of Health and Safety
IA2.3 IA2.4 3
Theories of loss causation
Quantitative analysis of accident/incident and ill‐
health data
Reporting and recording of injuries, ill‐health, dangerous occurrences and near‐misses
Loss and near‐miss investigations
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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Diploma Unit IA - Element IA2 - Loss causation and incident investigation
July 2014
Contents
Theories of loss causation
IA2.1
IA2.2 • Difference between a near‐miss and a fatal accident/incident in terms of time and distance can be very small
• The damage to persons or property is not the accident, but part of the effects of the accident/incident (i.e. the result or consequences)
• An old adage says “never waste an accident”
• Every accident/incident constitutes an opportunity to correct some problem
• A near‐miss which has the potential to cause loss is just as important as a serious injury/damage
IA2.3 IA2.4 Theories of loss causation
Quantitative analysis of accident/incident and ill‐
health data
Reporting and recording of injuries, ill‐health, dangerous occurrences and near‐misses
Loss and near‐miss investigations
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Accident/incident ratio studies and their use and limitations
Theories of loss causation
• Losses result from lack of control
• Revealed by loss causing events
• Definition of an accident is:
• Some years ago, a study of 1,750,000 accidents/incidents, in 21 industry sectors, led by Frank Bird, showed that there is a fixed ratio between accidents/incidents resulting in losses of different severity, including ones where no loss occurred, i.e. near misses)
• This can be demonstrated with an accident/incident ratio pyramid model
• An unplanned, uncontrolled event which led to, or could have led to injury to persons, damage to plant or some other loss to the company
• Definition includes ‘near‐misses', i.e. where no injury or damage etc. occurs
• Important not to think of injuries, damage and other losses as accidents/incidents, but rather as the results of accidents/incidents
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Accident/Incident/Near‐miss
Accident/Incident
Accident ratio study
Near‐miss
Source: Frank Bird.
Source: UK, HSG245.
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
2
Diploma Unit IA - Element IA2 - Loss causation and incident investigation
July 2014
Accident/incident ratio studies and their use and limitations
Accident ratio pyramid
Limitations
Source: UK, HSG96 the costs of accidents at work.
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• Frank Bird’s findings are not uniform throughout industry • The accident/incident ratio studies may not necessarily show the extent of the loss to the organisation
• There are no universally agreed definitions of each subset of accident type
• Statistical analysis of loss events relies on large numbers, comparable work and worker skills over the measured time‐
frame, to be effective
• In smaller organisations, the first recorded accident/incident may be the top event, i.e. fatality or major injury
• Near miss reporting may mean different things to different people
Domino and multi‐causality theories
Accident ratio triangle
• HW Heinrich proposed one of the first coherent theories of accident/incident causation in the mid 1920s
• Suggested that accidents/incident were not ‘acts of God’ but were caused by the failures of people
• His domino theory suggested that the series of events, which led to an injury or some other loss, were a succession of events which followed a logical pattern
Source: OGP, International Association of Oil & Gas Producers.
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Accident/incident ratio studies and their use and limitations
The domino theory
Accident causation domino
Use
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• If only those resulting in injury are considered, many opportunities to learn about what goes wrong are being missed
• If near misses are also studied they can provide more opportunities to learn and possibly prevent some of the events that result in injury
• The Frank Bird accident/incident pyramid model includes property damage in addition to near misses
• The accident/incident pyramid models help to convince people of the value of reporting a wide range of events and show that there are usually more near misses than injury events
Source: H.W. Heinrich.
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
3
Diploma Unit IA - Element IA2 - Loss causation and incident investigation
July 2014
Domino and multi‐causality theories
Domino and multi‐causality theories
The domino theory
Lack of management control
• Policy
• Planning
• Organising
• Controlling • Monitor
• Review
• Further research by the International Loss Control Institute (ILCI) into accident causation led them to put forward a modified domino theory
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The domino theory
Accident causation domino
Sequence of dominoes
Source: Frank Bird - ILCI.
Source: UK, HSG245.
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Domino and multi‐causality theories
Domino and multi‐causality theories
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Multiple accident causes
Loss
Event (accident/incident)
Immediate (direct) causes
Underlying (indirect or root) causes
• Usually more than one causative factor
• Each of the multiple causation factors may be seen as one domino in its own line of dominoes (just as the roots of a tree branch out)
• Organisational factors (Procedural)
• Job factors (Technical)
• Personal factors (Behavioural)
Source: RMS.
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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Diploma Unit IA - Element IA2 - Loss causation and incident investigation
Latent and active failures ‐ Reason’s model of accident causation
Contents
• Reason proposed four levels of human failure, each influencing the next
• The first level that Reason identifies is unsafe acts of persons, which ultimately lead to the accident/incident
• These unsafe acts were considered to relate to the errors, such as the skill‐based slips/lapses and mistakes identified in Rasmussen’s work in 1987 ‐ called active failures
• Reason identified three further levels of human failure that comprised latent failures
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July 2014
IA2.1
IA2.2 IA2.3 IA2.4 Theories of loss causation
Quantitative analysis of accident/incident and ill‐
health data
Reporting and recording of injuries, ill‐health, dangerous occurrences and near‐misses
Loss and near‐miss investigations
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Latent and active failures ‐ Reason’s model of accident causation
Quantitative analysis of accident/incident and ill‐health data
• The second level of human failure involves preconditions
that lead to unsafe acts taking place
• In many instances, these preconditions can be traced back to instances of unsafe supervision, the third level of human failure identified by Reason
• Importantly, Reason’s identified that causation did not stop at the supervisory level
• He recognised that the fourth level, the organisation itself, can impact on performance at all levels
• Analysis of accident/incident and ill‐health data allows general trends to be shown
• This data can also help to raise awareness in the minds of both managers and workers of health and safety in general and specific problems in particular
• Collection of data allows costs to be calculated, which can increase the likelihood of resources being allocated
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J. Reason’s accident/incident model
Part only of the complete Element IA2 – Loss causation and incident investigation
Source: Reason/RMS.
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Sample of PowerPoint presentation for NEBOSH International Diploma in Occupational Health and Safety
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